Analysis Failure of the Fire Detection System Immediately on being notified of the fire, the OOW manually activated the fire alarm system. He was soon relieved by the master and left the wheelhouse for his muster station. The master soon realized that the fire alarm had not sounded, and picked up the PA microphone to make a general call. He simultaneously activated the general alarm. On completion of his PA announcement, the general alarm started to annunciate. The sinking of the vessel precluded her examination. Consequently, the precise cause for the fire detection system failure could not be established. However, the most probable scenarios are as follows: A fault in the automatic fire detection system prevented it from detecting the fire and actuating the pre-alarm and the fire alarm. A momentary fault in the PA system overrode the alarm systems and prevented them from sounding. The fault cleared itself when the master used the PA system. Delay in Notifying the Authorities Between the time the fire was detected at 1545, and the time an initial notification was made to the MCTS at 1925, almost 3hours and 40minutes had elapsed. The master indicated that he didn't think it necessary to contact the MCTS as there were three other vessels in the area. He was also very busy in the wheelhouse with his own emergency duties. Instances are on record where appropriate authorities are not notified of the emergency in a timely manner. In another occurrence involving the F/VFame, the authorities were not notified until some 14hours following the emergency.8 The escalation of the emergency and the eventual notification of the authorities has the potential to compromise the safety of personnel as well as the safety of the vessel. Given that the success of a search and rescue (SAR) mission is dependent upon the prompt and efficient dispatch of SAR resources, it is essential that the authorities be notified as soon as an emergency situation arises. This permits the SAR authorities to identify, prepare and dispatch appropriate units and equipment in a timely manner in the event the emergency escalates and/or SAR assistance is required/requested. By not notifying SAR, the vessel as well as the shipboard personnel are placed in a vulnerable situation. In the event that the emergency is brought under control and assistance from the authorities is no longer required, the resources could then be stood down. In August 2001, a Ship Safety Bulletin (No.06/2001) was issued entitled Global Maritime Distress and Safety System (GMDSS) and Guidance on Important Operational Procedures. This bulletin, inter alia,provides guidance to masters in distress situations and emphasizes the importance of alerting search and rescue authorities at the earliest possible moment in any situation that may involve a danger to life or has the potential of developing into such a situation. To help ensure this information would be readily available to mariners, Transport Canada also arranged to have this information published in the CCG's Annual Edition of the Radio Aids to Marine Navigation. Location of the Fire The first fire party lead opened door D and entered a small foyer where he was met by a wall of smoke. Upon opening either doorEorF, he was met with heat and flame. The second fire party lead made it to doorD and when he opened it, he was met by a white flame which shot out over his head and hit the deckhead. DoorD provided access to the compartment which housed the spurling pipes and doorF provided access to the forward stores. This would suggest that the fire originated either in the compartment housing the spurling pipes or in the forward stores. There is no information to suggest that the compartment which housed the spurling pipes had combustible materials and a source of ignition. The housekeeping practices in the forward stores were poor. The supplies were stored both on deck or on shelving and were not secured. As such they were prone to being dislodged from their position due to the movement of the vessel in the 50-knot winds and 4-metre swell. Further, materials stored in the locker included: flammable material such as barbecue lighter fluid; chemicals/cleaning materials that in enclosed places have the potential to generate toxic fumes; and combustible materials such as paper products; all of which provided a source of fuel to the fire. The temperature in the forward stores was such that the doors were always kept open. Given that the space had a 5kWheater unit and that the compartment contained materials that are readily ignitable, it is highly likely that the fire originated in this compartment. Cause of the Fire As the vessel ultimately sank, the cause of the fire could not be determined. Boat and Fire Drills The vessel was a recent acquisition in late 2001 and Boat and Fire Drills were carried out on a regular basis. However, due to the short period the crew was on board this vessel (3-4months), relatively fewer drills had been performed. However in spite of the regulatory requirements,9 there was no indications that any fire hoses were ever run out, inspected and pressurized. A process that inspects and pressurizes hoses on a periodic basis as required by the regulations would permit the detection of deficiencies in a timely manner and would provide an opportunity to rectify the defect. The fact that no mock scenarios were used during the fire drills meant that when faced with a real life situation, the crew, although Marine Emergency Duties trained, was not completely familiar/comfortable with the duties at hand. As a result the crew was ill-prepared to put forward a cohesive and co-ordinated fire-fighting response. Fire Fighting The fire-fighting effort, while well intentioned, was ill-advised and poorly executed. A review of the Fire Drill Muster List indicated that the crew did not proceed to the designated emergency stations. Instead, each crew member reacted to the emergency situation and took upon themselves different roles leading to an uncoordinated response. This culminated in neither of the fire party leads (port or starboard) being properly attired with SCBA and protective fireman's outfit to fight the fire and both had to retract from the fire scene. In this instance, a fireman's outfit was at hand for use by the port fire hose party but none was readily available for the starboard fire hose party's use. The vessel was outfitted with two complete sets of SCBAs and fireman's outfits and one fireman's outfit was not available for use. The non-availability of one of the fireman's outfit for use may be attributable, in part, to personnel not adhering to the designated fire stations culminating in it being moved to a different location during fire-fighting activity. Given that the vessel carried two sets of SCBAs and two fireman's outfits, a single fire team in full protective gear and SCBAs would have been better prepared to fight the fire with a greater chance of success. Fire Containment The fire is believed to have started in a relatively small compartment,10 but quickly breached the compartment and ultimately consumed the entire vessel. The largest obstacle faced by the crew in attempting to fight the fire was the fact that many doors and hatches were open before the fire started, and even more were left open after the internal firefighting attempt was abandoned. In so doing, the fire progressed aft to the tween deck accommodation through the open collision bulkhead watertight door. The exact number is not known, but it was determined that several doors in the forward area of the tween deck accommodation were left open after the initial fire-fighting attempt failed. The open escape hatch from the forward storage locker allowed smoke to ventilate out to the forward mooring area, while an open door from the forward mooring area to the shelter deck lobby allowed smoke to flow into the lobby. The uncoordinated effort to fight the fire in conjunction with failure of some of the fire-fighting equipment further hampered fire-fighting activity. After being forced to abandon the attempt to fight the fire internally, the crew set up boundary cooling at four locations. One at the tween deck port side alleyway forward, a second at the tween deck starboard side alleyway forward, a third at the shelter (trawl) deck bulkhead forward, and a fourth on the forward shelter deck (storage locker deckhead). Although two areas of boundary cooling had been set up in the tween deck accommodation, it was discovered just prior to the final evacuation of the vessel that the port hose was shut-off and the starboard hose had failed (burst). Additionally one of the hoses supplying water to the forward shelter deck area failed when a hose clamp let go, requiring its repair. Running low on equipment , the vessel requested additional fire-fighting equipment from the other fishing vessels in the area. When the hoses were brought on board, it was discovered that the connections on the borrowed hoses were incompatible with the fire system (hydrants and hoses) on the Katsheshuk. This required the vessel's crew to quickly make up an adapter for one of the fire hydrants. In this instance, appropriate measures were not taken to contain the fire; containment of a fire being one of the factors that will positively influence the outcome of the fire-fighting effort. The closing of all doors would have enhanced the fire containment effort with a greater chance of success. The containment of the fire together with the boundary cooling would have provided an opportunity for the fire to burn itself out. Evacuation of Vessel Once conditions precluded fighting of the fire internally, the decision was made to evacuate all non-essential personnel. Initially the crew evacuated using the vessel's own rescue boat and those of nearby vessels. The crew would board the RB on the forecastle deck and then be lowered to the water by use of the starboard cargo crane. The number of personnel evacuated using the vessel's own rescue boat was reduced owing to the fact that the craft required two crew to operate it. An estimated four personnel transfers were carried out in this manner. Fearing a loss of power, the decision was then made to use a general purpose pilot ladder. The use of a pilot ladder required the crew to climb down the ladder to a rescue boat waiting alongside the vessel. From all accounts the starboard pilot ladder was in an unsatisfactory state with many loose or missing wooden rungs. Compounding the condition of the pilot ladder was the fact that the lower end was continually being hooked by the ice floes, causing the ladder to twist. Two crew members fell from the starboard pilot ladder during the evacuation. Rescue Boat The Katsheshuk had a 5.4m rescue boat equipped with a 40HP outboard motor which formed part of the vessel's safety equipment11. The remote steering control on the rescue boat was reported to have been unserviceable since mid-January2002. To allow for steerage, an improvised tiller arm (seePhoto5) had been jury-rigged to the outboard motor. This ad-hoc arrangement required the rescue boat to have two operating personnel, one to steer the vessel and a second to operate the throttle. The operational issues with the port boat davit during the evacuation could not be determined. several crew members did not carry out their emergency duties in accordance with the posted emergency duties plan; several doors were left in the open position some prior to and others following cessation of the fire-fighting activity; members of both fire hose teams were inadequately equipped (dressed) to fight a fire; and some fire-fighting equipment failed to operate as necessary. several crew members did not carry out their emergency duties in accordance with the posted emergency duties plan; several doors were left in the open position some prior to and others following cessation of the fire-fighting activity; members of both fire hose teams were inadequately equipped (dressed) to fight a fire; and some fire-fighting equipment failed to operate as necessary.Findings as to Causes and Contributing Factors several crew members did not carry out their emergency duties in accordance with the posted emergency duties plan; several doors were left in the open position some prior to and others following cessation of the fire-fighting activity; members of both fire hose teams were inadequately equipped (dressed) to fight a fire; and some fire-fighting equipment failed to operate as necessary. several crew members did not carry out their emergency duties in accordance with the posted emergency duties plan; several doors were left in the open position some prior to and others following cessation of the fire-fighting activity; members of both fire hose teams were inadequately equipped (dressed) to fight a fire; and some fire-fighting equipment failed to operate as necessary. The 3hour and 40minute delay in notifying authorities of the emergency precluded timely dispatch of search and rescue resources. Although required to by regulations, the fire hoses were not tested. This precluded the detection of deficiencies in a timely manner and the loss of opportunity to rectify them. The unsatisfactory condition of the starboard pilot ladder hampered the abandonment process and culminated in some of the crew sustaining injury. The practice of routinely keeping open the emergency escape hatch from the forward stores, the weathertight door to the forward stores and the access door from the mooring station to the shelter deck lobby is unsafe and risky.Findings as to Risk The 3hour and 40minute delay in notifying authorities of the emergency precluded timely dispatch of search and rescue resources. Although required to by regulations, the fire hoses were not tested. This precluded the detection of deficiencies in a timely manner and the loss of opportunity to rectify them. The unsatisfactory condition of the starboard pilot ladder hampered the abandonment process and culminated in some of the crew sustaining injury. The practice of routinely keeping open the emergency escape hatch from the forward stores, the weathertight door to the forward stores and the access door from the mooring station to the shelter deck lobby is unsafe and risky. The steering control for the rescue boat had been unserviceable for two months at the time of the occurrence.Other Findings The steering control for the rescue boat had been unserviceable for two months at the time of the occurrence. Safety Action Safety Concern Adequacy of Boat and Fire Drills on Fishing Vessels The Transportation Safety Board of Canada has already recognized the issue of preparedness and efficiency in drills. RecommendationM94-07, Fire and Boat Drills on Fishing Vessels recommended that Transport Canada ensure that the safety intent of the Boat and Fire Drill Regulationsis being fulfilled by owners and operators of fishing vessels. In response, Transport Canada issued Ship Safety Bulletin13/1999, titled Muster Lists and Practising of Emergency Procedures, reflecting the intent of drills, in that knowing what to do and being prepared for an emergency increases everyone's survivability and proves the equipment and the ability of crew. Boat and fire drills carried out on a regular basis, in accordance with the regulations, familiarize the crew in dealing with an emergency situation that may develop on board a vessel. In accordance with the intent of the Boat and Fire Drill Regulations, drills on board vessels like the Katsheshuk are to be carried out monthly, and the crew is to be familiarized and instructed with respect to the facilities of the vessel and their duties. Each crew member is to demonstrate such familiarity. Such drills include, inter alia, the running out, examination and pressurization of fire hoses, examination of smoke helmets, breathing apparatus and associated firefighting equipment, etc. Drills, therefore, improve crew efficiency, but also ensure the verification, testing and functionality of the equipment. The use of realistic scenarios while drills are conducted augments the level of preparedness, readiness and effectiveness. The Board is concerned that, despite efforts to improve the familiarity with equipment and competence of fishing vessel crew members in emergency situations, accidents like that on the Katsheshuk continue to put vessels and their crews at risk. The Board will continue to monitor these issues and will determine further safety action as required.